Telescoping Interspinous Fixation Device and Methods of Use

ABSTRACT

The present invention provides spinous process implants and associated methods. In one aspect of the invention, the implant includes at least one extension with a first part and a second part where at least one arm is coupled to each of the first part and the second part. The first part and the second part are movable from a compact to a distracted state. In another aspect, the present invention provides a second extension that is slidingly coupled to the first and second arms. The second extension further comprises a third part and a fourth part that move with the first and second part.

PRIORITY

This application claims priority under 35 U.S.C. §119 to U.S.Provisional Patent Application Ser. No. 61/583,219, filed Jan. 5, 2012,titled Telescoping Interspinous Fixation Device and Methods of Use,which is incorporated herein by reference as if set out in full.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is related to U.S. patent application Ser. No.11/934,604, filed Nov. 2, 2007, titled Spinous Process Implants andAssociated Methods, now U.S. Pat. No. 8,241,330; U.S. patent applicationSer. No. 12/020,282, filed Jan. 25, 2008, titled Spinal Implants andMethods; U.S. patent application Ser. No. 12/751,856, filed Mar. 31,2010, titled Spinous Process Implants and Associated Methods; U.S.patent application Ser. No. 12/538,710, filed Aug. 10, 2009, titledSpinous Process Implants, Instruments, and Methods; and U.S. patentapplication Ser. No. 12/854,125, filed Aug. 10, 2010, titledInterspinous Implants and Methods; U.S. patent application Ser. No.13/460,738, filed Apr. 30, 2012, titled Spinous Process Implants andAssociated Methods; and U.S. patent application Ser. No.; and U.S.patent application Ser. No. 13/584,661, filed Aug. 13, 2012, titledSpinous Process Implants and Associated Methods; all of which areincorporated herein by reference as if set out in full.

FIELD

The technology of the present application relates to spinal implantsand, more specifically, to an interspinous implant for fixation to oneor more spinous processes of a spine.

BACKGROUND

The vertebrae of the human spine are arranged in a column with onevertebra on top of the next. An intervertebral disc lies betweenadjacent vertebrae to transmit force between the adjacent vertebrae andprovide a cushion between them. The discs allow the spine to flex andtwist. With age or injury, spinal discs begin to break down, ordegenerate, resulting in the loss of fluid in the discs, andconsequently, the discs become less flexible. Likewise, the discs becomethinner allowing the vertebrae to move closer together. Degenerationalso may result in tears or cracks in the outer layer, or annulus, ofthe disc. The disc may begin to bulge outwardly. In more severe cases,the inner material of the disc, or nucleus, may actually extrude out ofthe disc. In addition to degenerative changes in the disc, the spine mayundergo changes due to trauma from automobile accidents, falls, heavylifting, and other activities. Furthermore, in a process known as spinalstenosis, the spinal canal narrows due to excessive bone growth,thickening of tissue in the canal (such as ligament), or both. In all ofthese conditions, the spaces through which the spinal cord and thespinal nerve roots pass may become narrowed leading to pressure on thenerve tissue which can cause pain, numbness, weakness, or even paralysisin various parts of the body. Finally, the facet joints between adjacentvertebrae may degenerate and cause localized and/or radiating pain. Allof the above conditions, as well as others not specifically mentioned,are collectively referred to herein as spine disease.

Conventionally, surgeons treat spine disease by attempting to restorethe normal spacing between adjacent vertebrae. This may be sufficient torelieve pressure from affected nerve tissue. However, it is oftennecessary to surgically remove disc material, bone, or other tissuesthat impinge on the nerve tissue and/or to debride the facet joints.Most often, the restoration of vertebral spacing is accomplished byinserting a rigid spacer made of bone, metal, or plastic into the discspace between the adjacent vertebrae and allowing the vertebrae to growtogether, or fuse, into a single piece of bone. The vertebrae aretypically stabilized during this fusion process with the use of boneplates and/or pedicle screws fastened to the adjacent vertebrae.

Although techniques for placing intervertebral spacers, plates, andpedicle screw fixation systems have become less invasive in recentyears, they still require the placement of hardware deep within thesurgical site adjacent to the spine. Recovery from such surgery canrequire several days of hospitalization and long, slow rehabilitation tonormal activity levels.

Rather than spinal fusion, investigators have promoted the use of motionpreservation implants and techniques in which adjacent vertebrae arepermitted to move relative to one another. One such implant that has metwith only limited success is the artificial disc implant. The artificialdisc typically includes either a flexible material or a two-piecearticulating joint inserted in the disc space. Another such implant isthe spinous process spacer which is inserted between the posteriorlyextending spinous processes of adjacent vertebrae to act as an extensionstop and to maintain a minimum spacing between the spinous processeswhen the spine is in extension. The spinous process spacer allows theadjacent spinous processes to move apart as the spine is flexed. Theextension stop spacers, however, also have had limited success.

Recently, the trend has been back towards fusion devices rather thanmotion preservation devices. One promising recent implant is a spinalprocess fusion plate. Similar to the fusion implants, the spinal processfusion plate promotes fusion between adjacent vertebrae to relievepressure on the nerve. However, unlike more conventional spinal implantsystems, the spinal process fusion plate facilitates less invasiveprocedures than conventional spinal fusion surgery. The need stillexists for improved spinal process fusion plates to facilitate even lessinvasive surgery including, minimally invasive surgery, percutaneousimplantation, and the like. Such less invasive surgery may beaccomplished by an implant that may be implanted in a more compact orrelatively compact state and expanded or enlarged state.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the technology of the present application will bediscussed with reference to the appended drawings. These drawings depictonly illustrative examples of the technology described more fully hereinand are not to be considered limiting of its scope.

FIG. 1 is a posterior cross sectional view of an implant in situ that isdeployed using a tool consistent with the technology of the presentapplication;

FIG. 2 is a side elevational view of the implant of FIG. 1 in situ;

FIG. 3 is an exploded perspective view of the implant of FIG. 1;

FIG. 4 is a posterior elevational view of the implant of FIG. 1;

FIG. 5 is an anterior elevational view of the implant of FIG. 1;

FIG. 6 is a top plan view of the implant of FIG. 1;

FIG. 7 is a posterior elevational view of the implant of FIG. 1 showingthe assembly in an alternate position;

FIG. 8 is a side elevational view of the implant of FIG. 1;

FIG. 9 is a perspective view of a pair of implants like that of FIG. 1in situ;

FIGS. 10A-D are views of an implant that is consistent with thetechnology of the present application;

FIG. 11 is a perspective view of a part of the implant;

FIG. 12 is a perspective view of a part of the implant;

FIG. 13 is a perspective view of a part of the implant;

FIG. 14 is a view of a part of the implant;

FIG. 15 is a view of a part of the implant;

FIG. 16 is a view of a part of the implant;

FIG. 17 is a view of a part of the implant;

FIG. 18 is a view of a part of the implant;

FIG. 19 is a view of part of the implant;

FIG. 20 is a view of part of the implant;

FIG. 21 is a perspective view of a part of the implant;

FIG. 22 is a view of a part of the implant;

FIG. 23 is a perspective view of a part of the implant;

FIG. 24 is a view of a part of the implant;

FIGS. 25-27 are views of parts of the implant consistent with thetechnology of the application;

FIGS. 28-30 are views of parts of the implant consistent with thetechnology of the application;

FIGS. 31-33 are view of a screw associated with the implant consistentwith the technology of the application; and

FIGS. 34-40 are view of tools usable with the technology of theapplication.

DESCRIPTION OF THE ILLUSTRATIVE EXAMPLES

The technology of the present application will be described in thecontext of spinal surgery, but one of ordinary skill in the art willrecognize on reading the disclosure that the technology may beapplicable to other medical fields. Moreover, the technology of thepresent application will be described with reference to certainexemplary embodiments. The word “exemplary” is used herein to mean“serving as an example, instance, or illustration.” Any embodimentdescribed herein whether or not specifically identified as “exemplary”is not to be construed as preferred or advantageous over otherembodiments. It also should be understood that terminology employedherein is used for the purpose of describing particular embodiments onlyand is not intended to be limiting. It must be noted that, as used inthis specification, the singular forms “a,” “an,” and “the” includeplural references unless the context of the disclosure clearly dictatesotherwise. Thus, for example, reference to “a lithium hydroxide” is notto be taken as quantitatively or source limiting, reference to “a step”may include multiple steps, reference to “producing” or “products” of areaction should not be taken to be all of the products of a reaction,and reference to “reacting” may include reference to one or more of suchreaction steps. As such, the step of reacting can include multiple orrepeated reaction of similar materials to produce identified reactionproducts.

Further, the instrument(s) described in accordance with the technologyof the present application facilitate surgical implantation of spinalprocess fusion plates. With that in mind, exemplary spinous processimplants, according to the technology, may include a spacer and anextension extending outwardly from the spacer. The extension, which maybe referred to as a wing, is sometimes described as being one or morelobes associated with the spacer. In certain aspects, the spacer may beintegral or monolithic with one of the extensions. In other aspects, thespacer may be separate from all of the associated wings. The spinousprocess implant may be configured for insertion between adjacent spinousprocesses of the cervical, thoracic, and/or lumbar spine. The spacer maybe provided in a variety of sizes to accommodate anatomical variationamongst patients and varying degrees of space correction. The spacer andextensions may include openings, recesses, pockets, etc. to facilitatetissue in-growth to anchor the spacer to the vertebral bodies such astissue in-growth from the spinous processes. The spacer may beconfigured for tissue in-growth from superior and inferior spinousprocesses to cause fusion of the adjacent spinous processes. Theopenings may be relatively large and/or communicate to a hollow interiorof the spacer or a hole, pocket, or recess in the extensions. A hollowinterior may be configured to receive bone growth promoting substancessuch as by packing the substances into the hollow interior. The openingsmay be relatively small and/or comprise pores or interconnecting poresover at least a portion of the spacer surface. The openings, howeverformed, may be filled with bone growth promoting substances.

In certain aspects, the implant may be described as telescoping. Atelescoping implant may generally be described as an implant that hasmultiple parts where at least a portion of the parts comprises a maleprotrusion that slidably engages a female socket to allow the maleprotrusion to slidably engage the female socket. A telescoping spinousprocess fusion plate may offer a number of functional advantages overother implants, such as a fixed length spinous process fusion plate. Incertain embodiments, the telescoping spinous process fusion plate mayprovide: (1) compression of fixation devices extending from theextensions into one or more spinous processes, then manipulating theimplant to compress or distract the interspinous space by providing acompact or enlarged configuration of the implant, (2) may compress orlordose when using a posterior interbody (transforaminal lumbarinterbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) forexample) to reduce the risk of expulsion from the fusion site, (3)distraction without (or without compressing) the fasteners extendingfrom the extension to allow for functionality similar to an adjustableheight extension stop, and (4) facilitate implantation by providing acompact insertion state and an enlarged or expanded distraction state.

A compact or reduced height insertion state may be particularly usefulwhen the supraspinous ligament (SSL) is left intact as the compact orcollapsed height of the telescoping implant may be approximately four(4) millimeters to about ten (10) millimeters. In certain aspects thecollapsed height of the implant may be four (4), six (6), or eight (8)millimeters. However, if the SSL is sacrificed or removed, the implantmay be fully assembled and inserted directly to the interspinous spaceusing a posterior approach. Providing a compact height of 4-8 or 4-10millimeters may provide for a smaller incision and surgical corridor.Moreover, the compact or reduced height of the implant (reduced ascompared to the expanded or enlarged height) also may facilitateimplantation when the posterior aspects of the spinous process areabutting or in close proximity, sometimes referred to as “kissing.”Also, when the SSL is sacrificed, the telescoping implant may be aunitary unit with extensions attached to both sides of the spacer.

Whether unitary or modular, the extension may extend transversely fromthe spacer relative to a spacer longitudinal axis to maintain the spacerbetween adjacent spinous processes. The extension may be described asfoldable, extendable, deployable or the like from a flat configurationto facilitate minimally invasive implantation to an extended position tofacilitate fusion. A single extension may extend in one or moredirections or multiple extensions may be provided that extend inmultiple directions. One or more extensions may be adjustablelongitudinally relative to one another and/or the spacer to allow theextensions to be positioned laterally relative to the spinous processes.A moveable extension may be provided that is moveable axially relativeto the spacer and another extension. Alternatively, a plurality ofmoveable extensions may be provided. For example, the extensions mayclamp against the sides of the spinous processes to immobilize thespinous processes relative to one another and promote fusion between theadjacent vertebrae. The extensions may include fasteners engageable withthe spinous processes. The fasteners may include sutures, wires, pins,straps, clamps, spikes, screws, teeth, adhesives, and/or other suitablefasteners. The fasteners may be integrated into the extensions or theymay be modular. Modular fasteners may be adjustable, replaceable, and/orremovable to allow tailoring of the kind and quality of fixation fromrigid fixation to no fixation. The spacer, extensions, and/or fastenersmay advantageously be made of different materials. For example, thespacer and extensions may be made of a relatively softer material whilethe fasteners may be made of a relatively harder material. For example,the spacer and/or extension may be made of a polymer and/or otherrelatively soft material and the fastener may be made of a metal and/orother relatively hard material.

Insertion of spinous process implants may be facilitated by a set ofinstruments alternately engageable with one another to increase theinterspinous space and engageable with a spinous process implant to helpmaneuver it between adjacent spinous processes as has been described insome of the related applications described above and incorporated byreference. Moreover, instruments for the present spinous process implantmay facilitate percutaneous operation whether through a cannula, tube,or lumen. The instruments may include mechanisms to facilitatetelescoping, unfolding, opening, or deploying portions of the implantincluding the extensions and spacer. The instruments may include a drawinternal or external to the spacer to pull the extensions in a directionsuch that the extensions are pried apart by a wedge or ramp.

It has been found that presently available interspinous implants, suchas the device explained with reference to FIGS. 1-9, are good atstabilizing a spinal segment to allow it to fuse. The interspinousimplant could be implanted with less tissue trauma percutaneously orthrough a tube, cannula, or lumen if the spacer was provided in acompact state and expanded to a distraction state subsequent to theplacement of the spacer between adjacent spinous processes. In certainembodiments, the implant, when in the compact state, fits within thespace between adjacent spinous processes without abutting both processesand in some cases, may fit within the space without abutting eitherspinous process until the implant is partially expanded.

In other embodiments, the implant may slightly distract the spinousprocesses when in the compact state. Expanding the spacer to thedistraction state may be subsequent to manual distraction of thevertebral bodies or may be in conjunction with expanding the spacer.Expanding the spacer may be accomplished by providing a spacer body witha superior and inferior portion that have internal surfaces that areramped to cooperatively engage an internal body that is wedge shaped orramped such that drawing the internal body laterally through aninterspinous space may cause at least one of the superior and inferiorportions to move apart in a distraction direction. In other embodiments,the spacer may be mounted on a post that telescopes into a bore suchthat the post may be expanded from the bore to cause expansion. In stillother embodiments, the extensions may have a post and socket where thepost and socket allow for ratcheted movement to telescope the spacer.

In certain embodiments, one or both of the extensions may be a foldableor collapsible extension to further compact the implant prior toplacement. One or more of the extensions may have offset fasteners onthe foldable extension and corresponding bores into which the fastenersmay fit to allow a flat or nearly flat configuration of the folded wingfor the most compact delivery possible. The foldable extensions may foldabout an axle or be hinged to allow for movement. A draw, rod, or hookmay be connected to the hinge or axle to pull the hinge or axle towardsthe spacer that causes the face or surface of the extension to run upagainst an edge that forces the folded extension to unfold. In someembodiments, internal rods and ramps may be used to force the foldedextension to unfold or open.

For completeness, reference will now be made to FIGS. 1-9 describing anexemplary embodiment of a spinous process implant with a fixed andnon-expandable spacer as well as at least one fixed or non-foldableextension. As will be explained further below, the spacer may bereplaced with an expandable or telescoping spacer that is expandablebefore or after implantation from a compact or insertion state to adistraction or expanded state. While specific exemplary embodiments areprovided herein, implants associated with any of the incorporatedapplications or similar spinous process fusion plates may benefit fromthe technology of the present application to allow telescoping orexpanding implants with or without extensions or wings that fold tofacilitate implantation. Moreover, it may be especially beneficial toincorporate a foldable extension with the technology of the presentapplication to allow for a compact implant for delivery throughminimally invasive procedures, for example.

FIGS. 1 and 2 depict posterior and lateral views of a pair of adjacentvertebrae of the lumbar spine 10. A superior vertebra 12 is separatedfrom an inferior vertebra 14 by a disc 16. Each vertebra includes a pairof transverse processes 18, 19, a posteriorly projecting spinous process20, 21, and a pair of lamina 22, 23 connecting the transverse processes18, 19 to the spinous process 20, 21. In addition to the connectionthrough the disc 16, the vertebrae 12, 14 articulate at a pair of facetjoints 24.

FIGS. 1-9 illustrate an exemplary spinous process implant 100. Theimplant 100 includes a spacer 102 positioned between the spinousprocesses 20, 21. The geometry of the implant 100 is illustrated withthe use of axes that define length (l), height (h), and width (w)directions for the spacer. When implant 100 is implanted in a patient,the height direction of the spacer 102 is generally oriented along thesuperior/inferior direction of the patient's anatomy, the widthdirection of the spacer 102 is generally oriented along theanterior/posterior direction of the patient's anatomy, and the lengthdirection of the spacer 102 is generally oriented along thelateral/medial direction of the patient's anatomy.

The height 104 (FIG. 1) of spacer 102 limits how closely the spinousprocesses 20, 21 can move together. As the implant in this example is afusion plate, the height also limits how distantly the spinous processes20, 21 can move apart. Thus, the spacer 102 maintains a minimum andmaximum distance between the spinous processes 20, 21. In the case ofspine disease involving posterior subsidence of the adjacent vertebra,insertion of the spacer 102 between the spinous processes 20, 21 willmove the vertebrae apart and relieve pressure on nerve tissue and thefacet joints 24.

As shown in FIG. 3, the spacer 102 includes a first end 106, a secondend 108, and a longitudinal axis 110 extending from the first end to thesecond end. The spacer 102 has a sidewall 112, generally parallel to thelongitudinal axis 110, including superior and inferior outer surfaces114, 116. Transverse openings 118 (see also FIG. 6) communicate from thesuperior and inferior outer surfaces 114, 116 inwardly to facilitatetissue in-growth. The exemplary spacer 102 includes a hollow interior120 bounded by an inner surface 122 such that the openings 118communicate from the outer surfaces 114, 116 to the hollow interior 120.Bone growth promoting substances 124 are shown packed into the hollowinterior 120 in FIGS. 1 and 2 to promote fusion of the vertebrae 12, 14by bone growth between the spinous processes 20, 21.

The spinous process implant 100 further includes a first extension 126projecting outwardly from the spacer 102 along the spacer heightdirection h and transversely to the longitudinal axis 110 to liegenerally alongside the superior and inferior spinous processes 20, 21.Abutment of the first extension 126 with the spinous processes 20, 21helps prevent lateral movement of spacer 102, thereby maintaining spacer102 between the spinous processes 20, 21. In the exemplary spinousprocess implant 100, the first extension 126 is fixed relative to thespacer 102. When fixed, the first extension 126 may be generally unitarywith spacer 102 or the first extension 126 and spacer 102 may form amonolithic unit. The implant 100 also includes a second extension 128mountable to the spacer for axial movement relative to the firstextension 126. The second extension 128 may be moved toward the firstextension 126 to approximate the width of the spinous processes 20, 21and better stabilize the implant 100. It is fixed in place by tighteninga set screw 130 (FIG. 3) against the spacer 102. The extensions 126, 128include fasteners 132, 134, 136 projecting from the extensions 126, 128to engage the spinous processes 20, 21 to fix the spacer 102 to thespinous processes 20, 21. FIG. 1 depicts an additional bone growthpromoting substance in the form of strips of bone 125 sandwiched betweenthe extensions 126, 128 along the sides of the spinous processes 20, 21to promote bone growth along the sides of the spinous processes tofurther enhance fusion of the vertebrae 12, 14. As an alternative tostrips of bone 125, the bone 125 may be formed similar to a washer orring to cooperatively fit about the fasteners 132, 134, 136 to promotebone growth. While the extensions 126, 128 may extend in only one ofinferiorly or superiorly from the spacer 102, the extensions 126, 128preferably extend inferiorly as well as superiorly from spacer 102 tooptionally attach to both the inferior and superior spinous processes toimmobilize the spinous processes 20, 21 relative to one another whilefusion takes place.

Fasteners 132, 134, and 136 may take any suitable form. They may be madeintegral with the extensions 126, 128 such as by machining or castingthem with the extensions or they may be formed separately andpermanently attached to the extensions 126, 128. Fastener 132 is asharpened spike that threadably engages the extension 126. The threadedengagement allows the fastener 132 to be replaced with a differentfastener 132. For example, the fastener 132 may be replaced by one thathas a different shape, a different size, a different material, or adifferent surface coating. The threaded engagement also allows thefastener 132 to be adjusted to extend by varying amounts from theextension 126 to vary how it engages the bone. Thus, the fastener 132can be adjusted to fit differently shaped bones or to penetrate into abone by varying amounts. For example, multiple threaded fasteners 132can be adjusted to extend by different amounts to conform to curved orangled bone. Finally, the threaded engagement allows the user to removethe fastener 132 when fixation is not desired such as when it is desiredto use implant 100 in a non-fusion procedure as an extension stopwithout limiting flexion.

As best seen in FIG. 3, fasteners 134 and 136 are provided asmulti-spike pods allowing a plurality of spikes to be quickly adjusted,changed, or omitted. Fastener 134 includes a non-circular tab 138engageable with a non-circular opening 140 in the extension 126. Thenon-circular engagement prevents the fastener 134 from rotating. The tab138 may form a press-fit, snap-fit, or other suitable engagement withthe opening 140. The tab 138 may be further secured by a supplementalscrew 142. Fastener 136 includes a threaded shaft 144 threadably engagedwith a base member 146 to allow the length of the fastener 136 to beadjusted. The shaft 144 engages the extension 126 in a rotating andpivoting manner such that the fastener 136 can be adjusted rotationallyand angularly to engage the bone surface. In the illustrativeembodiment, the shaft 144 terminates in a spherical ball 148 thatengages the opening 140 in a ball-and-socket arrangement for threedegrees of freedom. However, any mechanism that allows any number ofdegrees of freedom may be used. The fastener 136 may be allowed to movein use so that as the extension 126 is pressed toward a bone, thefastener 136 adjusts to the angle of the bone surface. The fastener 136also may be secured, such as by screw 142, to adjust the tension in thejoint and/or to lock the fastener 136 in a predetermined orientation.

FIG. 4 illustrates the axial relationship of fasteners on the opposingextensions 126, 128. In the illustrative implant 100, the fasteners 132at the top of the implant 100 are shown aligned along a common axis 150that is substantially perpendicular to extensions 126 and 128. Thefasteners 134 at the bottom of the implant 100 are shown offset so thatthey can interleave, if necessary, as they are pressed into a bone. Anycombination of fastener type, number, and alignment may be provided onthe implant 100.

As seen in FIGS. 5 and 6, the ends 106, 108 of the spacer 102 includeanterior chamfers 152. These chamfers 152 allow the ends 106, 108 toclear posteriorly facing structures of the vertebrae 12, 14 such as thefacet joints 24. Also, as seen in FIGS. 5 and 6, the spacer 102 isoffset anteriorly (in the spacer width direction w) relative to theextensions 126, 128 such that the longitudinal axis 110 of the spacer102 is anterior of a midline plane 154 (FIGS. 6, 8) of the extensions126, 128. The anterior offset of the spacer 102 allows it to fit deeplybetween the spinous processes 20, 21 while the extensions 126, 128 fitalongside the spinous processes 20, 21.

As best seen in FIGS. 3 and 8, the second extension 128 defines anaperture 155 conforming generally to the cross-sectional shape of thespacer 102. In the illustrative embodiment of FIGS. 1-9, the aperture155 opens anteriorly to form a “C”-shape, although the aperture 155could conform to the entire cross-section of the spacer to form a “D” or“O” shape, for example. In the exemplary embodiment, aperture 155forming a generally “C”-shape includes tabs 156 that extend inwardlyfrom the superior and inferior portions of the aperture to slidinglyengage elongated slots 158 in the superior and inferior surfaces of thespacer 102. The second extension 128 can be translated longitudinallyalong the spacer length l toward and away from the first extension 126.Tightening the set screw 130 against the posterior side 160 of thespacer 102 forces the tabs 156 posteriorly against the sides of theslots 158 and locks the second extension 128 in place longitudinally.The tabs 156 may increase towards the tip of the tabs 156 to facilitateengagement with the slots 158 in the spacer 102. The tabs 156 may behooked shaped as well instead of straight or expanding to facilitate thecooperative engagement. The posterior side 160 of the spacer 102 may beroughened as shown to better grip the set screw 130. The set screw 130may also dig into the surface of the spacer 102 upon tightening topositively grip the spacer 102. The aperture 155 (FIGS. 3, 8) mayconform closely to the spacer 102 to constrain the second extension 128to generally parallel motion relative to the first extension 126.Alternatively, the aperture 155 may be larger than the spacer 102 by apredetermined amount to permit a predetermined amount of angularadjustment of the second extension 128 relative to the first extension126 as shown in FIG. 7 to allow the extension 128 to adjust to theunderlying bone surface.

As best seen in FIG. 8, the second extension 128 includes a firstinferior lobe 161 having a first lobe centerline 162 and a secondsuperior lobe 164 having a second lobe centerline 166. In theillustrative embodiment, the first lobe centerline 162 and the secondlobe centerline 166 are parallel and spaced apart so that the secondextension 128 has a generally “Z”-shaped plan form. This shape allowsthe extension of one implant 100 to interleave, if necessary, withanother implant 100 in a multilevel surgery (as shown in FIG. 9) topermit close spacing of the implants, and/or longer extension lobes formore extensive bone engagement. In addition, first inferior lobe 161 hasa semi-circular convex shape that is generally complementary to asemi-circular superior concave surface 165 formed adjacent secondsuperior lobe 164. Similarly, second superior lobe 164 has asemi-circular convex shape that is generally complementary in shape to asemi-circular inferior concave surface 163 formed adjacent firstinferior lobe 161. As indicated in FIG. 8, first inferior lobe 161 isadjacent to inferior concave surface 163, and extension midline plane154 is located between first inferior lobe 161 and inferior concavesurface 163. Second superior lobe 164 is adjacent superior concavesurface 165, and extension midline plane 154 is located between secondsuperior lobe 164 and superior concave surface 165. Moreover, firstinferior lobe radius r₁ is substantially equal to superior concavesurface radius r₄, while second superior lobe radius r₃ is substantiallyequal to inferior concave surface radius r₂. As a result, when twoimplants are placed on adjacent spinal levels, the first inferior lobe161 of the upper implant may be (but need not be, depending on what ismedically indicated) interfitted into the superior concave surface 165of the inferior implant. In addition, the second superior lobe 164 ofthe inferior implant may be interfitted into the inferior concavesurface 163 of the superior implant. In the illustrative example ofFIGS. 1-9, first inferior lobe 161 and second superior lobe 164 form aunitary second extension 128. Although not separately depicted, firstextension 126 also has complementary lobes that are similarly configuredand oriented relative to one another.

As shown in FIG. 9, multiple spinous process implants 100 may be placedon adjacent levels of the spine. As illustrated in the figure, a firstsuperior implant 100 is positioned with its spacer 102 between a firstsuperior spinous process and a second intermediate spinous process,while a second inferior implant 100 is positioned with its spacer 102between the second intermediate spinous process and a third inferiorspinous process. The first extensions 126 of the superior and inferiorimplants are located on a first side of the patient's sagittal plane,while the second extensions 128 of the superior and inferior implantsare located on a second side of the patient's sagittal plane.

In the illustrative embodiment of FIGS. 1-9, the extension lobecenterlines 162,166 are offset equidistantly from the midline plane 154of the second extension 128. Although not separately shown, the firstextension 126 is configured similarly. The centerlines 162, 166 may varyfrom parallel and they may be offset asymmetrically to form differentshapes to accommodate different vertebral anatomy. For example, theshape may be tailored for different portions of the spine 10. In theillustrative embodiment of FIGS. 1-9, the first extension 126 has thesame shape as the second extension 128. However, the shape may be variedbetween the first and second extensions 126, 128.

As shown in FIGS. 1-9, the first extension 126 is integral or unitarywith the spacer 102 and second extension 128 has an aperture 155 that isshown to partially surround the spacer to allow the second extension 128to translate over the outer surface of the spacer 102. In certainembodiments, especially smaller implants, the aperture 155 may form athrough hole in second extension 128 to completely surround the spacer102.

Now, with reference to the remaining FIGS., an implant 200 is described.The implant 200 is shown in FIGS. 10A, 10B, and 10C in a posterior/leftlateral view (10A), a right lateral/posterior view (10B), and ananterior/right lateral view (10C) in a partially expanded state. Inother words, the implant 200 is not shown completely compacted orcompletely expanded. As shown, the implant 200 includes a firstextension or wing 202 and a second extension or wing 204. The firstextension 202 may be referred to as the post plate because a pluralityof arms 206 (which will be explained further below) may be monolithicwith the first extension 202. In the embodiment shown in FIGS. 10A-10D,the plurality of arms 206 are cantilevered from the first extension orpost plate 202 along a horizontal or transverse axis 201. The secondextension 204 may be referred to as the lock plate because it isgenerally free to move with respect to the plurality of arms 206 untilit is locked in place (as will be explained further below). FIG. 10Dshows implant 200 in a fully or close to fully extended or distractedstate 208. As can be appreciated, the spacer 102 of implant 100 has beenreplaced by four (4) arms 206 extending from first extension 202. One ofordinary skill in the art on reading the disclosure, however, would nowunderstand that the plurality of arms 206 is only one exemplaryembodiment of the present technology and the plurality of arms 206 maybe replaced by more, less, or differently configured members thatfunction as the spacer.

As shown in FIGS. 10A-D, the first and second extensions 202, 204 havemedial sides 203 with fasteners, such as fasteners 132 described above.The fasteners on the medial sides 203 may include any of the fastenersdescribed above or in any of the incorporated applications.

With reference to FIGS. 11-13, the first extension 202 and the pluralityof arms 206 of implant 200 are shown. The first extension 202 includes afirst part 208 (FIG. 12) and a second part 210 (FIG. 13). The first andsecond parts 208, 210 have an anterior facing side 212 and a posteriorfacing side 214. The first and second parts 208, 210 further include ananterior arm 206 a ₁ and 206 a ₂ and a posterior arm 206 p ₁ and 206 p₂. While shown as two anterior arms and posterior arms, the plurality ofarms 206 may include more or less arms. For example, anterior arm 206 a₁ may be formed contiguous with posterior arm 206 p ₁. Alternatively,there could be more arms, such as an anterior arm, a posterior arm, andan interior arm. The arms 206 a ₁ and 206 p ₁ of the first part 208 havea top surface 216. The arms 206 a ₂ and 206 p ₂ of the second part 210have a bottom surface 218. A distance 220 between the top surface 216and the bottom surface 218 is adjustable, as will be explained below,from a minimum to a maximum distance.

As seen in FIG. 12, the first part 208 has a central portion 222 thatextends from the anterior facing side 212 to the posterior facing side214. As used herein, central portion should not be construed to mean amiddle, midline, or other geometric reference. Rather the phrase centralportion is a designator that the portion is between, for example,inferior and superior extending parts as will be explained furtherbelow. A threaded bore 224 opens towards the posterior facing side 214.As will be explained further below, a set screw or the like isthreadably engaged with the threaded bore 224 to lock the first part 208at a height when the distance 220 is the desired spacing between thesuperior and inferior spinous processes.

Extending in an inferior direction from the central portion 222 is amale member 226. The male member 226 is on the anterior side of thefirst part 208. The male member 226 has a vertical axis 228. Extendingin a superior direction from the central portion 222 is a female member230. The female member 230 generally conforms to, for example, the lobesaddressed above with respect to FIGS. 1-9. In other words, the femalemember 230 generally conforms to a superior lobe described above. Thefemale member 230 is generally hollow and forms a socket 232. The femalemember also has a vertical axis 234 offset in a posterior direction fromthe vertical axis 228. The female member 230 has an opening 236 at bothends of the socket 232 to reduce the material and overall profile of theimplant. The top opening 236 could be closed with a web of material.However, the female member 230 would need to extend to a greater heightalong the vertical axis 234 to accommodate a similar sized male member.

The male member 226 has a plurality of indentations 238, rack cutouts,ratchets, gears, or teeth. A tool, not shown in FIGS. 11-13, has aplurality of corresponding protrusions to engage the teeth. Rotating theprotrusions on the tool acts as a pinion gear and causes the male member226 to move up or down along the vertical axis 228. With reference toFIG. 10D, a tool 1 is shown attached to the first extension 202. Thetool may have an arm 2 that terminates in a protrusion (not shown) thatengages a detent or hole 3 on the first extension 202. A pinion gear maybe contained in a housing 4 to engage the indentations. The pinion gearmay be rotated by a dial (not shown) connected to a handle distal to thehousing 4 using, for example, a worm drive or the like.

As seen in FIG. 13, the second part 210 has a central portion 238 thatextends from the anterior facing side 212 to the posterior facing side214. Extending in a superior direction from the central portion 238 is amale member 240. The male member 240 is on the posterior side of thesecond part 210. The male member 240 has a vertical axis 242 that issubstantially aligned with vertical axis 234 of the female member 230 onthe first part 208. The male member 240 is sized for telescopic movementin and out of the socket 232. The male member 240 may have surfacetexturing 243 in a posterior face to engage a set screw, or the like,threaded into threaded bore 224 (above). Extending in an inferiordirection from the central portion 238 is a female member 244. Thefemale member 244 generally conforms to the inferior lobes describedabove with respect to FIGS. 1-9. The female member 244 is generallyhollow and forms a socket 246. The female member also has a verticalaxis 248 that is substantially aligned with the vertical axis 228 of themale member 226 of the first part 208. The socket 246 is sized to allowtelescopic movement of male member 226 in and out of the socket 246. Thesocket 246 forms a through bore in the female member such that hasopenings 250 on the top and bottom, although the bottom opening 250 maybe closed with a web of material.

A lateral side 252 of the female member 244 has an opening or window254. The indentations 238 of the male member 226 are visible through thewindow 254. The tool, explained above but not shown in FIGS. 11-13, hasprotrusions that extend through the window 254 to engage theindentations.

FIGS. 14-17 show implant 200 in a compact state 260. FIG. 13 shows aview along the horizontal axis 201 of the lateral side 252 of the firstextension 202. The first part 208 and the second part 210 are shownabutting along an edge 262. The first and second part 208, 210 do notneed to abut along the edge 262, but allowing the first and second parts208, 210 to abut provides a low profile. Prior to implantation, theimplant 200 may be held assembled in the compact state 260 using a pin264 in a pin hole 266 where the pin 264 extends through the femalemember 230 of the first part 208 and engages the male member 240 of thesecond part 210, such as, for example, by engaging a groove 256.Alternatively, set screw 268 could be threaded into threaded bore 224 tohold the parts together.

The female members 230, 244 are shown extending in the superior andinferior direction, respectively. The male member 222 is shown fullyinserted into socket 246 and visible through window 254. The male member240 is fully inserted into socket 232, but not visible in the lateralview.

FIG. 15 shows the first extension 202 from a posterior view in thecompact state 260. In the compact state 260, the first extension 202 hasa height 270. The posterior arms 206 p ₁ and 206 p ₂ abut in the compactstate 260 to provide a low profile in the compact state (in other words,the height 270 is as small as possible), although they could be slightlyseparated. The first extension 202, including the plurality of arms,extends in the horizontal direction a length 272.

FIG. 16 shows the first extension 202 from a medial view in the compactstate 260. In the compact state 260, the anterior arms 206 a ₁ and 206 a₂ nest such that anterior wall members 276, 277 are in a slidingrelationship when in the compact state. The anterior wall members may bereferred to herein as vertical wall members, anterior flaps, or thelike. The posterior arms 206 p ₁ and 206 p ₂ abut, but could be designedto nest similar to the anterior arms 206 a ₁ and 206 a ₂. As shown, eachof the arms for a vertical wall and an overhang 278 forming a quasichamber 280 into which bone growth may occur. Additionally, bone growthpromoting substances may be contained in the chamber 280.

FIG. 17 shows the first extension 202 from an anterior view in thecompact state 260. As can be appreciated with respect to FIGS. 17 and18, where FIG. 18 shows a superior view of the first extension, theanterior arms 206 a ₁ and 206 a ₂ extend from the medial side 203 alength 282. The anterior arms may terminate in a chamfered terminal end283 to facilitate implantation of the implant 200. Similarly, theposterior arms 206 p ₁ and 206 p ₂ extend from the medial side 203 alength 284. As shown, the length 284 of the posterior arms is longerthan the length of the anterior arms 282 by a distance represented by286. The shorter anterior arms facilitate clearing portions of theanatomy, such as the facet, during certain implantation procedures.

FIG. 19 shows the first extension 202 in the fully extended state 288 inboth a lateral and posterior view. The first extension 202 in theextended state 288 has a maximum height 290 greater than the height 270in the compact state. The extended state 288 may be referred to as thedistracted or distraction state. As can be appreciated, the firstextension 202 may be moved from the compact state 260 to an extendedstate where the height is less than the maximum height 290 shown in FIG.19. The set screw 268 engaging the texture 243 holds the first part 208and the second part 210 in position once the position is set by thesurgeon.

The first extension 202 provides dual male-female telescoping members asdescribed above. The dual telescoping members allow for the plate tosubstantially change height while maintaining a sufficient aspect ratioto reduce frictional binding during actuation and also to increaserigidity of the final construct. In some embodiments, the male-femaletelescoping pairs are arranged so that the female member of eachtelescoping feature is positioned offset so that the male member of eachtelescoping feature fully resides inside the member, with no protrusionsin the compact state. Such an arrangement prevents or helps preventinterference when nesting additional plates at the adjacent levels formultilevel use. In some embodiments, two implants are used to connectacross or collectively span two adjacent interspinous spaces. In otherembodiments, three or more implants are used to connect across three ormore interspinous spaces. Additionally, it can be appreciated now thatthe male members and the female members may be reversed and the abovedescription including lateral, medial, superior, inferior, anterior, andposterior directions or guides is to facilitate identification ofdifferent pieces and parts of the device and should not be consideredlimiting.

With reference back to FIGS. 10A-D, the second extension 204, which issometimes referred to as the lock plate, comprises a third part 300 anda fourth part 302, both of which are shown in a lateral view alonghorizontal axis 201 in FIG. 20. The third part 300 and fourth part 302similar to the first part 202 and second part 204 have an anteriorfacing side 212 and a posterior facing side 214. As shown, third part300 includes a pin hole 301 that receives a pin 303. As will beexplained below, the pin 303 extends through pin hole 301 and looselycouples the third part 300 and the fourth part 302.

FIG. 21 shows an anterior, lateral perspective view of the third part300. The third part 300 includes a central portion 304 with a posterior,female member 306 extending in a superior direction from the centralportion 304. The female member 306 generally conforms to a superior lobeof the section extension described above with respect to FIGS. 1-9. Thefemale member 306 is generally hollow forming socket 308 and has avertical axis 310. The central portion 304 of the third part 300includes a threaded bore 312 that receives a set screw 314 to lock thethird part 300 to the fourth part 302, as will be explained furtherbelow.

An anchor 316 or truncated male member extends in an inferior directionfrom the central portion 304. As shown in FIG. 22, the anchor 316 has ashort post 318 that terminates in a flanged surface 320. The centralportion 304, post 318, and flanged surface 320 form a first interiorcavity 322. With reference back to FIG. 16, for example, the firstcavity 322 is shaped to cooperatively, and slidingly, engage theposterior arm 206 p ₁, which includes the overhang 278. Similarly, thecentral portion 304, post 318, and flanged surface 320 form a firstexterior cavity 324, which may be sometimes referred to as a carve outor groove. The first exterior cavity 324 is shaped to cooperatively, andslidingly, engage the overhang 278 of the anterior arm 206 a ₁. As canbe appreciated, the more snugly the cavities 322 and 324 fit the arms206 p ₁ and 206 a ₁, the less movement is provided. Increasing the sizeof the cavities may provide the ability to orient the third part 300with respect to the patient anatomy. In the embodiment shown, thecavities are provided with an angled or chamfered surface 321 thatprovides the ability to adjust the angle of the third part in thecoronal plane. The angle may be from about 0° degrees to about 10 or insome cases 15°.

With reference now to FIG. 23, a view of the fourth part 302 is shown.The fourth part comprises a central portion 326. A posterior, malemember 328 extends in a superior direction posterior facing side of thecentral portion 326. The male member 328 extends along a vertical axis330. The vertical axis 330 of the male member 328 generally aligns withthe vertical axis 310 of the socket 308 or female member 306. The malemember 328 is sized for telescopic movement in and out of the socket308. The male member 328 may include a channel. An anterior member 332extends in an inferior direction from the central portion.

An anchor 334, generally corresponding in size, form, and function tothe anchor 316 above, extends in a superior direction from the centralportion 326 as best seen in FIG. 24. The anchor 334 includes a shortpost 336 that terminates in a flanged surface 338. The central portion326, post 336, and flanged surface 338 form a second interior cavity340. With reference back to FIG. 16, for example, the second cavity 340is shaped to cooperatively, and slidingly, engage the posterior arm 206p ₂, which includes the overhang 278. Similarly, the central portion326, post 336, and flanged surface 338 form a second exterior cavity342, which may be sometimes referred to as a carve out or groove. Thesecond exterior cavity 342 is shaped to cooperatively, and slidingly,engage the overhang 278 of the anterior arm 206 a ₂. As can beappreciated, the more snugly the cavities 340 and 342 fit the arms 206 p₂ and 206 a ₂, the less movement is provided. Increasing the size of thecavities, may provide the ability to orient the fourth part 302 withrespect to the patient anatomy. Similar to the cavities above, thecavities are provided with an angled or chamfered surface 321 thatprovides the ability to adjust the angle of the third part in thecoronal plane. The angle may be from about 0° degrees to about 10 or insome cases 15°. Notice, the anterior arms and the posterior arms areeach similarly shaped such that the first and second internal cavities,and the first and second external cavities, all have generally the sameshape.

The posterior face 344 of the male member 328 includes surface texturing243 similar to the posterior face of male member 240 described above.Thus, when the male member 328 is telescoped in female socket 308 to adesired position, the set screw 314 may be threaded in threaded bore 312until the set screw engages the surface texturing 243 to secure thethird part 300 with respect to the fourth part 302.

The anterior member 332, while hollow, does not form a socket similar tothe other members described herein; in part, because third part 302 hasan anchor 316 rather than a male member extending from the third part300 in an inferior direction. Also, anterior member 332, which is shownin cross-section in FIG. 25, provides a means for coupling the secondextension 204 to the plurality of arms 206, and more specifically, tothe posterior arm 206 p ₂ in this exemplary embodiment. As shown,anterior member 332 provides an elongate chamber 346 that has aposteriorly extending tool port 348 arranged in this embodiment belowcentral portion 326. The elongate chamber 346 extends from the bottom ofanterior member 332 to the flanged surface 338. The short post 336 has aposterior port 350 which is shown extending completely through shortpost 336 of anchor 334, but is only needed to extend from the elongatechamber 346 to the second internal cavity 340. A plunger 352 resides inthe posterior port 350. The plunger 352 couples to the posterior arm 206p ₂ to hold the second extension 204 in place during the surgicalprocedure. In this exemplary embodiment, the plunger 352 may beconsidered a ratcheted plunger as the plunger 352 has a plurality ofteeth 354 that engage corresponding teeth 356 (FIG. 18) on the posteriorarm 206 p ₂. The plunger is coupled to a spring arm 360, such as, by thespring arm 360 extending into a bore 358. The spring arm 360 biases theplunger in a posterior direction such that the plunger extends from theposterior port 350 to engage the posterior arm 206 p ₂. As can beappreciated, the teeth are shaped to allow movement of the secondextension toward the first extension without disengaging the plunger352. However, to move the second extension away from the firstextension, a tool needs to extend into tool port 348 to engage springarm 360. The tool would move spring arm 360 in an anterior direction toallow the plunger 352 to disengage such that the second extension may bemoved away from the first extension. FIG. 27 shows a view of the teeth354 of the plunger 352 extending through posterior port 350 into thesecond internal cavity 340.

FIG. 28 shows a cross sectional view of the plurality of arms 206including the anterior arms 206 a ₁ and 206 a ₂, and the posterior arms206 p ₁ and 206 p ₂. Each of the arms has an overhang 278. The fourarms, in this exemplary embodiment, form a quasi-chamber 280 into whichtissue growth or bone growth material may be placed to facilitatefusion. Also, the plurality of arms 206, as well as the first and second202, 204 extension may include surface texturing, roughing, plasmacoating, or the like to facilitate tissue and bone growth. Further, asmentioned above, more or less arms 206 are possible such as, forexample, a midline arm 206 m ₁ and 206 m ₂ as shown in phantom.Additionally, the posterior arms 206 p ₁ and 206 p ₂ comprise a mainbody 362 from which the overhang 278 extends. The anterior arms 206 a ₁and 206 a ₂ have an anterior wall member 364 from which the overhang 278extends. The anterior wall member may comprise different heights, asshown in phantom, from about two (2) millimeters to about eight (8)millimeters. The anterior wall members 364 together form a largeranterior wall to facilitate retention of any tissue or bone growthmaterial placed in quasi-chamber 280. As can be appreciated, the smalleranterior wall members 364 of approximately 2 mm would be used in smallerapplications of the present technology, such as, for the cervical spinespace; whereas, the larger anterior wall members 364 of approximately 8mm would be used in larger applications of the present technology, suchas the lumbar spine space. The anterior wall members 364 could haveheights of three (3), four (4), five (5), six (6), seven (7) or even upto about ten (10) millimeters depending on the application. As can beappreciated, in the compact state, the anterior wall memberssubstantially abut or overlap. As the implant is expanded or distracted,the anterior wall members slidingly move against each other to theexpanded state.

Alternatively, as shown in FIG. 29, a floating wall 366 may be providedbetween the anterior wall members 364. The floating wall 366 isslidingly and moveably coupled to one or both of the anterior wallmembers 364. Additionally, while only one floating wall 366 is shown,multiple floating walls 366 may be layered to provide differentextension lengths. In one exemplary embodiment, the floating wall 366may have a tongue 368 with a flare 370 that engages a groove 372 andstop 374 on the anterior wall members 364, as shown partially explodedin FIG. 30.

As mentioned above, once distracted, the first and third parts 208, 300may be locked to the male members 240, 328, of the second and fourthparts 210, 302 of the implant 200. In the exemplary embodiment provided,set screws 268, 314 are threaded into threaded bores 224, 314respectively. An exemplary set screw 376 is shown in FIGS. 31 and 32.The set screw 376 has a threaded body 378 that cooperatively engages thethreads of threaded bores 224, 314. The set screw 376 also has, in thisexemplary embodiment, a non-threaded tip 380 that terminates in an edge382, which is circular in this embodiment. The set screw 376 may have aninternal bore 384 adapted to engage a driver (not shown). The bore 384may have a number of undulations 386 or the like to facilitateengagement with the driver, such as a hex driver, hexalobular, stardriver, or the like. The set screw 376 is shown in cross-section in FIG.33. The edge 382 of the set screw 376 engages the surface texturing 243on the male members 240, 328 to form a cup point connection as isgenerally known in the industry. To facilitate the cup point connection,the surface texturing may be scooped, or dual crescent, shaped to matchthe curvature of the edge 382.

Some exemplary tools and instruments usable with the implant 200 will beshown and described with reference to the remaining FIGS. While sometools are specifically shown, it should be understood that other anddifferent tools may be used to accomplish many of the functions of thetechnology of the present application.

A driver 400 may be provided as shown in FIG. 34. The driver 400 has ashaft 402 with a proximal end 404 and a distal end 406. The distal end406 may terminate in a tip 408, such as, for example, a conventional hexor star shape, to cooperatively engage the bore 384 of the set screws.The proximal end 402 may be sized and designed to facilitate rotation ofthe driver by hand.

A compressor 410 may be provided as shown in FIG. 35. The compressor 410includes two members 412 pivotally connected. The pivotal connection 414may comprise a pin 416, or axle, coupling the two members 412 together.Each of the members 412 has a handle or grip 418 at a proximal end 420of the compressor 410 and a tip 422 at the distal end 424 of thecompressor. The grips are biased apart by springs 426, such as, forexample, leaf springs. When the grips 418 are compressed togetheragainst the springs 426, the tips 422 compress the first and secondextensions 202, 204 together. A lock bar 428 maintains the grips 418 inthe compressed state until the lock bar is manually lifted, at whichtime the springs open the compressor 410. The tips may be textured tofacilitate gripping the first and second extensions. As can beappreciated, multiple compressors 410 may be required for smoothcompression of the multiple parts of the first and second extensions.

With reference now to FIGS. 36 and 37, a combination inserter andexpander tool 450 is provided. FIG. 36 shows a view of the tool 450 andFIG. 37 shows a cross-sectional view of the tool 450. The tool 450 has aproximal end 452 with an enlarged grip 454 to improve the surgeon'sability to grip the tool 450; however, the grip 454 does not need to beenlarged. The tool also has a distal end 456 for connection to theimplant 200, as will be explained further below. The distal end 456 isadapted to be moved from outside the body of a patient to the surgicalsite. The handle or grip 454 is connected to a shaft nut 462 that isconnected to the shaft 460. The shaft 460 terminates in a tip 458.

The grip 454 terminates at an end 461 that may include a display face462. The display face 462 may have indicia 463 corresponding to thedistraction to be provided to the spinous processes. The display face462 and indicia are coupled to a proximal end of a drive axle 464. Thedrive axle 464 extends along a longitudinal axis 466 of the tool 450from the proximal end to the tip 458 at the distal end 456. The proximalend of the drive axle 464 is coupled to a worm gear 468 such thatrotation of the worm gear 468 rotates the drive axle 464. The worm gear468 meshes with a threaded portion 470 (worm) of a transverse axle 472having a transverse axis 474 that is perpendicular to the longitudinalaxis 466. The transverse axle 474 extends through a bore 476 towards theend of the grip 454. As shown, each end of the transverse axle 474terminates in rotatable tabs 478, which may be thumb wheels or the like.Rotation of the tabs 478 causes the worm gear 468 to rotate, which inturn rotates the drive axle 464 and the display face 462. A pinion gear480 contained in the tip 458 has teeth 482 that mesh with theindentations 238 or rack cutouts to drive the male member into or out ofthe associated female member.

FIG. 39 shows the tip 458 in more detail without the pinion gear 480 orthe drive axle 464. The tip 458 may include a removable cap 484 suchthat the pinion gear 480 may be replaced or refurbished as required. Thetip 458 further has an engagement detent 486. The engagement detent 486couples to an inserter tool bore 488 (FIG. 10A) such that the tool 450may be releasably coupled to the implant 200. While the engagementdetent 486 may form a 90° angle with respect to the longitudinal axis466, the engagement detent 486 may be angled slightly towards theproximal end of the tool 450 such that the engagement detent 486 extendsat an acute angle a in the posterior direction. The acute angle aprovides a better connection between the tool 450 and the implant 200.

In certain applications, the implant 200 may be partially assembledexterior to a patient prior to implantation. In other cases, the firstextension 202 and the plurality of arms 206 may be implanted first andthe second extension 204 inserted subsequent to the arms being extendedthrough the interspinous space. To facilitate movement of the secondextension 204, a second extension inserter 500 is provided as shown inFIG. 40. Inserter 500 includes a pistol grip 502 comprising a post 504and a movable trigger 506. The moveable trigger 506 is biased away fromthe post 504 by a pair of cooperating springs 508, such as, for example,leaf springs. Extending along a longitudinal axis is a stationary shaft510 coupled to post 504. The shaft 510 is called the stationary shaft asit does not move relative to the post 504. A movable shaft 512 isslidingly coupled to the stationary shaft and the trigger 506. Movingthe trigger 506 towards the post 504 in a direction A about the pivotaxle 514 causes the movable shaft 512 to move in a direction B relativeto the stationary shaft 510. A lock 516, such as the shown thumb lock,may be moved into place to maintain the tool in the grip positionagainst the springs 508.

The movable shaft 512 has a tip 522 that extends into the posteriorlyextending tool port 348, which may bias the spring arm 360 to disengagethe plunger 352 from posterior arm 206 p ₂ and allow movement of thesecond extension 204 away from the first extension 202. In this manner,the second extension 204 may be translated relative to the firstextension 202 without ratcheting. The ratchets may then be reengaged byremoving tip 522 from port 348 to help secure the second extension 204at the desired time or location. The stationary shaft 510 has aprotrusion 518 that engages an opening or detent on the lateral surfaceof the second extension 204 to help retain shaft 510 thereto.

A housing 520 is coupled to the movable shaft 512 a distance d along themovable shaft 512 from a tip 522. The housing 520 contains a compressionmember 524, such as a spring. Extending from the housing 520 toward thetip 522 is an arm 526, wherein the spring and arm may be considered aspring loaded arm. The arm 526 has a flanged gripping surface 528 toprovide a frictional gripping force when the trigger 506 is movedtowards the post 504 such that the tool 500 can grip the secondextension 204.

As herein, “about” refers to a degree of deviation. based onexperimental error typical for the particular property identified. Thelatitude provided the term “about” will depend on the specific contextand particular property and can be readily discerned. by those skilledin the art. The term “about” is not intended to either expand or limitthe degree of equivalents which may otherwise be afforded a particularvalue. Further, unless otherwise stated, the term “about” shallexpressly include “exactly,” consistent with the discussions regardingranges and numerical data. Concentrations, amounts, and other numericaldata may he expressed or presented herein in a range format. It is to beunderstood that such a range format is used merely for convenience andbrevity and, thus, should be interpreted flexibly to include not onlythe numerical values explicitly recited as the limits of the range, butalso to include all the individual numerical values or sub-rangesencompassed within that range as if each numerical value and sub-rangeis explicitly recited. As an illustration, a numerical range of “about 4percent to about 7 percent” should be interpreted to include not onlythe explicitly recited values of about 4 percent to about 7 percent, butalso include individual values and sub-ranges within the indicatedrange. Thus, included in this numerical range are individual values suchas 4.5, 5.25 and 6 and sub-ranges such as from 4-5, from 5-7, and from5.5-6.5; etc. This same principle applies to ranges reciting only onenumerical value. Furthermore, such an interpretation should applyregardless of the breadth of the range or the characteristics beingdescribed.

Notwithstanding that the numerical ranges and parameters setting forththe broad scope of the invention are approximations, the numericalvalues set forth in the specific examples are reported as precisely aspossible. Any numerical value, however, inherently contain certainerrors necessarily resulting from the standard deviation found in theirrespective testing measurements.

It will be clear that the systems and methods described herein are welladapted to attain the ends and advantages mentioned as well as thoseinherent therein. Those skilled in the art will recognize that themethods and systems within this specification may be implemented in manymanners and as such is not to be limited by the foregoing exemplifiedembodiments and examples. In other words, functional elements beingperformed by a single or multiple components, in various combinations ofhardware and software, and individual functions can be distributed amongsoftware applications at either the client or server level. In thisregard, any number of the features of the different embodimentsdescribed herein may be combined into one single embodiment andalternate embodiments having fewer than or more than all of the featuresherein described are possible.

While various embodiments have been described for purposes of thisdisclosure, various changes and modifications may be made which are wellwithin the scope of the present invention.

Numerous other changes may be made which will readily suggest themselvesto those skilled in the art and which are encompassed in the spirit ofthe disclosure.

We claim:
 1. An apparatus comprising: a first extension having a lateralfacing side and a medial facing side, the medial facing side adapted toreside proximate a first surface of a spinous process, the firstextension defines a horizontal axis that extends substantiallyperpendicular to the medial facing side, the first extension comprising:a first part comprising a first male member extending in an inferiordirection along a first vertical axis and a first female memberextending in a superior direction along a second vertical axis, thefirst female member defining a first socket; a second part comprising asecond male member extending in a superior direction along a thirdvertical axis and a second female member extending in an inferiordirection along a fourth vertical axis, the second female memberdefining a second socket, wherein the third vertical axis issubstantially aligned with the second vertical axis such that the secondmale member is telescopically received in the first socket and thefourth vertical axis is substantially aligned with the first verticalaxis such that the second male member is telescopically received in thesecond socket; and a plurality of arms cantilevered from the medialfacing side of the first extension and extending a distance along thehorizontal axis, at least a first arm of the plurality of armscantilevered from the first part and at least a second arm of theplurality of arms cantilevered from the second part, wherein the firstextension comprises a compact state such that the first arm and thesecond arm form a first height and a distracted state such that thefirst arm and the second arm form a second height greater than the firstheight.
 2. The apparatus of claim 1, wherein the first arm comprises afirst anterior arm and a first posterior arm coupled to the first partand the second arm comprises a second anterior arm and a secondposterior arm coupled to the second part.
 3. The apparatus of claim 1,wherein the plurality of arms form a chamber adapted to contain materialto promote tissue growth.
 4. The apparatus of claim 2, wherein at leastone of the first and second anterior arms and the first and secondposterior arms comprise an overhang.
 5. The apparatus of claim 4,wherein each of the first and second anterior arms and the first andsecond posterior arms comprise an overhang.
 6. The apparatus of claim 5,wherein the first anterior arm comprises a first wall member extendingfrom the first anterior arm towards the second anterior arm, and thesecond anterior arm comprises a second wall member extending from thesecond anterior arm towards the first anterior arm.
 7. The apparatus ofclaim 6, wherein the first wall member and the second wall member areconfigured to slidingly move with respect to each other as the firstextension moves between the compact state and the distracted state. 8.The apparatus of claim 1, wherein the first male member comprises aplurality of indentations and the lateral facing side of the second partcomprises a window adapted to provide access to the plurality ofindentations.
 9. The apparatus of claim 1, wherein the first partcomprises an anterior facing side and a posterior facing side, whereinthe first male member resides on the anterior facing side and the firstfemale member resides on the posterior facing side, and furthercomprising a bore extending from the posterior facing side to thesocket.
 10. The apparatus of claim 9, further comprising a fasteneroperatively coupled to the bore such that the fastener extends throughthe bore and releasably couples to the second male member, whereby thefirst part and the second part are locked in place with respect to eachother.
 11. The apparatus of claim 10, wherein the fastener comprises athreaded set screw and the bore comprises a threaded bore, and whereinthe second male member comprises surface texturing on a posterior faceto cooperatively engage a leading edge of the set screw.
 12. Theapparatus of claim 11, wherein the surface texturing is crescent shaped.13. The apparatus of claim 1, wherein the medial facing side comprisesat least one fastener extending in a direction along the horizontal axisand adapted to operatively couple to a spinous process.
 14. Theapparatus of claim 1, wherein the first and second sockets extendcompletely through the first and second female members.
 15. Theapparatus of claim 1, further comprising: a second extension comprisinga lateral facing side and a medial facing side, the medial facing sideadapted to reside proximate a second surface of the spinous processopposite the first surface, the second extension comprising: a thirdpart defining a first interior cavity sized to slidingly engage at leastthe first arm; a fourth part defining a second interior cavity sized toslidingly engage at least the second arm, wherein the third part and thefourth part are movable with the first part and the second part from thecompact state to the distracted state.
 16. The apparatus of claim 15,wherein: the third part comprises a third female member extending in asuperior direction along a fifth vertical axis, the third female memberdefines a third socket, and the fourth part comprises a third malemember extending in a superior direction along a sixth vertical axissubstantially aligned with the fifth vertical axis, wherein the thirdmale member is telescopically received in the third socket.
 17. Theapparatus of claim 16, wherein the third part comprises a first anchorextending in an inferior direction and wherein the fourth part comprisesa second anchor extending in a superior direction whereby the first andsecond interior cavity are formed in part by the anchor.
 18. Theapparatus of claim 17, wherein the first and second anchors comprise apost terminating in a flanged surface.
 19. The apparatus of claim 18,wherein the first and second anchors further form first and secondexterior cavities.
 20. The apparatus of claim 15, wherein the secondextension is releasably and slidingly coupled to the plurality of arms.21. The apparatus of claim 20, wherein the fourth part comprises: afirst member comprising a port in communication with the second interiorcavity; and a movable plunger disposed in said port wherein the plungeris movable from a first position where the plunger engages the secondarm to a second position where the plunger disengages the second arm.22. The apparatus of claim 21, wherein the movable plunger is biased tothe first position with a spring.
 23. The apparatus of claim 21, whereinthe plunger comprises a first plurality of teeth that engage a secondplurality of teeth on the second arm.
 24. An implant having a portionadapted to be placed between spinous processes of adjacent vertebrae ofa spine in a first configuration and expandable to a secondconfiguration subsequently to being placed, the implant comprising: aspacer comprising a first spacer part having a top surface and a secondspacer part having a bottom surface, the first and second spacer partshaving a length along a horizontal axis configured to traverse a spacebetween adjacent spinous processes, the first and second spacer partsbeing movable from a first configuration where the top surface and thebottom surface are separated by a first distance to a secondconfiguration where the top surface and the bottom surface are separatedby a second distance that is greater than the first distance; a firstextension comprising a first extension part movably coupled to a secondextension part, the first extension comprising a laterally facing sideand a medially facing side, the first spacer part fixedly coupled to themedially facing side of the first extension part such that the firstspacer part and the first extension part move together, the secondspacer part fixedly coupled to the medially facing side of the secondextension part such that the second spacer part and the second extensionpart move together; a second extension comprising a third extension partand a fourth extension part, the second extension comprising a laterallyfacing side and a medially facing side, the third extension partslidingly coupled to the first spacer part to allow the third extensionpart to move generally parallel to the horizontal axis along the firstspacer part, the fourth extension part slidingly coupled to the secondspacer part to allow the fourth extension part to move generallyparallel to the horizontal axis along the second spacer part, the thirdand fourth extension parts movable with the first spacer part and thesecond spacer part from the first configuration to the secondconfiguration; and a plurality of fasteners comprising at least a firstfastener coupled to the medially facing side of the first extension andsecond fastener coupled to the medially facing side of the secondextension wherein the first and second fasteners are adapted to piercethe bone of at least one of the adjacent spinous processes.
 25. Theimplant of claim 24, wherein the first spacer part comprises a pluralityof first arms and the second spacer part comprises a plurality of secondarms.
 26. The implant of claim 25, wherein: the plurality of first armscomprises at least a first anterior arm comprising a first anterior flapand a first posterior arm; and the plurality of second arms comprises atleast a second anterior arm comprising a second anterior flap and asecond posterior arm, such that the first and second anterior arms, thefirst and second anterior flaps, and the first and second posterior armform a chamber.
 27. The implant of claim 24, wherein the first extensionfurther comprises at least a first male member having a first verticalaxis coupled to one of the first extension part or the second extensionpart and at least a first female member having a second vertical axiscoupled to the other of the first extension part or the second extensionpart whereby the first male member is slidingly received in the firstfemale member.
 28. The implant of claim 24, wherein: the first extensionpart comprises an anterior male member extending along a first verticalaxis and a posterior female member extending along a second verticalaxis; and the second extension part comprises a posterior male memberextending along the second vertical axis and telescopically received inthe posterior female member and an anterior female member extendingalong the first vertical axis to telescopically receive the anteriormale member.
 29. The implant of claim 24 wherein the third extensionpart comprises a first anterior anchor forming a first interior cavityshaped to slidingly receive the first spacer part and the fourthextension part comprises a second anterior anchor forming a secondinterior cavity shaped to slidingly receive the second spacer part. 30.The implant of claim 29 wherein the first and second anchors comprise apost and a flanged surface.
 31. The implant of claim 24, wherein: thethird extension part comprises at least one of a posterior male memberor a posterior female member having a vertical axis, and the fourthextension part comprises a corresponding one of a posterior femalemember or a posterior male member having a vertical axis so that thethird and fourth extensions are telescopically coupled.
 32. A method oftreating spine disease comprising: providing an implant having a firstextension having a laterally facing side and a medially facing side, thefirst extension comprising a first part and a second part wherein thefirst part and the second part are movable over a movement axisgenerally parallel to a plane defined by the medially facing side, thefirst part comprising at least a first arm fixedly coupled to themedially facing side of the first part and extending in a directiontransverse to the movement axis, the second part comprising at least asecond arm fixedly coupled to the medially facing side of the secondpart and extending in the direction transverse to the movement axis, theimplant having a compact configuration wherein the first arm and thesecond arm are separated by a first distance and a distractedconfiguration wherein the first arm and the second arm are separated bya second distance greater than the first distance; inserting the implantin the first configuration until the first extension is proximate afirst side of at least one spinous process and the first and second armstraverse an interspinous space between adjacent spinous processes;moving the first part and the second part from the first configurationwherein the first and second arms are separated by a first distance tothe second configuration wherein the first and second arms are separatedby a second distance; locking the first part and the second parttogether such that the first part and the second part maintain thesecond distance.
 33. The method of claim 32, wherein the providedimplant further comprises a plurality of fasteners coupled to themedially facing side of the first extension and the wherein the step ofinserting comprises causing the plurality of fasteners to bite into thefirst side of the at least one spinous process.
 34. The method of claim32, wherein the provided implant further comprises a second extension,and further comprising translating the second extension over the firstarm and the second arm until the second extension is proximate a secondside of the at least one spinous process.